LiDCO Outcomes Studies
Review of published outcome & utility studies
Enhanced recovery after surgery (ERAS) in Open Liver Resection (OLR): Initial Leeds experience
This study evaluated the applicability of ERAS in OLR and to compare its outcome with a historical cohort after OLR.
A multimodal enhanced recovery protocol was developed in order to minimize the effects of surgery on post-operative pathophysiology. This included Goal Directed Fluid Therapy using (LiDCO) as a means of post-operative fluid optimization. A stroke volume guided protocol was developed to enable nurse and practitioner staff in the PACU and HDU to administer fluid challenges, in order for them to determine whether an alteration in patient’s physiological parameters is due to a change in systemic vascular resistance or cardiac output and to action accordingly.
Only OLR were included. Two groups were defines, Group Pre-ERAS July 2012 – December 2014) and Group-ERAS (January 2015-June 2016). This was not a controlled study. The Primary endpoint was length of hospital stay (mean ± SD). Secondary endpoints were HDU stay, postoperative complications. Significance was defined as p < 0.05.
Between July 2012 and June 2016 a total of 630 OLR were performed. The group Pre-ERAS included 419 patients and the group-ERAS had 211. After comparing the main demographics in both cohorts, patients in the ERAS group were significantly younger. Re-do OLR were more frequent in the non-ERAS group.
The study was able to implement our ERAS-LR in all cases. A significant reduction in the overall LOS in the ERAS group was observed. Within the subset of patients older than 70 and major resections only, a significantly shorter LOS was witnessed. The incidence of postoperative complications was reduced within the ERAS group (p< 0.05).
The study concluded that the ERAS Program for liver surgery was feasible in all patients. No detrimental effects were recorded and a benefit was perceived, with a reduced length of hospital stay, and possibly reduced overall morbidity rates. Though stronger evidence is required, ERAS in LR is believed to improve outcomes as it has been shown in other surgical disciplines.
Jeffery J, Upasani V, Igasan R, Ward D, Toogood G, Prasad KR, Lodge JP, Hidalgo E
Propensity Score Analysis of an Enhanced Recovery Programme in Upper Gastrointestinal Cancer Surgery
This study examined the influence of an enhanced recovery programme (ERP) on outcomes of upper gastrointestinal (UGI) cancer surgery by means of propensity score-matched analysis.
Three hundred consecutive patients diagnosed with UGI cancer were studied prospectively before and after the introduction of an ERP. Multiple regression models, including propensity scores, were developed to assess confounding variables associated with undergoing surgery, and the risk adjusted association between treatment and length of hospital stay (LOHS).
An arterial and central venous line was used in all patients. Goal directed fluid therapy was monitored with the aid of the lithium dilution cardiac output (LiDCO) rapid
The results of this study showed that:
ERP operative morbidity (Clavien–Dindo C3) and mortality were 13.8 and 3.1 % compared with 17.4 (p = 0.449) and 2.2 % (p = 0.658)
Median ERP critical care and total LOS were 1 (IQR 0–1) and 13 (IQR 10–17) days, compared with 1 (IQR 1–2, p = 0.009) and 16
(IQR 13–26, p\0.001) days.
Multivariable analysis revealed ERP (HR 1.477, 95 % CI 1.084–2.013, p = 0.013), tumour location (HR 2.420, 95 % CI 1.624–3.606, p\0.001),
operative procedure (HR 1.143, 95 % CI 1.032–1.265, p = 0.010), and operative morbidity (HR 0.277, 95 % CI 0.179–0.429, p\0.001) to be
associated with LOHS.
An ERP in UGI cancer surgery was feasible, safe, and effective.
A. Karran, J. Wheat, D. Chan, P. Blake, R. Barlow, W. G. Lewis
Effect of Perioperative Goal-Directed Hemodynamic Resuscitation Therapy on Outcomes Following Cardiac Surgery: A Randomized Clinical Trial and Systematic Review
The objective of this study was to evaluate the effects of goal-directed therapy on outcomes in high-risk patients undergoing cardiac surgery.
Patients were randomized to a cardiac output guided hemodynamic therapy algorithm (goal-directed therapy group, n = 62) or to usual care (n = 64).
In the goal-directed therapy arm, a cardiac index of greater than 3 L/min/m2 was targeted with IV fluids, inotropes, and RBC transfusion starting from cardiopulmonary bypass and ending 8 hours after arrival to the ICU.
A cardiac output monitor LiDCOrapid was connected to the arterial cable, and variables of cardiac index and stroke volume index (SVI) were used as goals to deliver the hemodynamic intervention.
LiDCOrapid (LiDCO) is a calibrated beat-to-beat monitoring system that uses the pulse power analysis, a technique that assumes the difference between the amount of blood entering the circulation and the blood flowing out peripherally (20).
The LiDCOrapid was calibrated at baseline by inputting the cardiac index value obtained by the echocardiogram.
The primary outcome was a composite endpoint of 30-day mortality and major postoperative complications. Patients from the goal-directed
therapy group received a greater median (interquartile range) volume of IV fluids
Than the usual care group (1,000 [625–1,500] vs 500 [500–1,000] mL; p < 0.001], with no differences in the administration of either inotropes
or RBC transfusions.
The primary outcome was reduced in the goal-directed therapy group (27.4% vs 45.3%; p = 0.037).
The goal-directed therapy group had a lower occurrence rate of infection (12.9% vs 29.7%; p = 0.002) and low cardiac output syndrome
(6.5% vs 26.6%; p = 0.002).
We also observed lower ICU cumulative dosage of dobutamine (12 vs 19 mg/kg; p = 0.003) and a shorter ICU (3 [3–4] vs 5 [4–7] d;
p < 0.001) and hospital length of stay (9 [8–16] vs 12 [9–22] d; p =0.049) in the goal-directed therapy compared with the usual care group.
There were no differences in 30-day mortality rates (4.8% vs 9.4%, respectively; p = 0.492). The metaanalysis identified six trials and showed
that, when compared with standard treatment, goal-directed therapy reduced the overall rate of complications (goal-directed therapy, 47/410
[11%] vs usual care, 92/415 [22%]; odds ratio, 0.40 [95% CI, 0.26–0.63]; p < 0.0001) and decreased the hospital length of stay (mean difference,
–5.44 d; 95% CI, –9.28 to –1.60; p = 0.006) with no difference in postoperative mortality: 9 of 410 (2.2%) versus 15 of 415 (3.6%), odds ratio,
0.61 (95% CI, 0.26–1.47), and p = 0.27.
Goal-directed therapy using fluids, inotropes, and blood transfusion reduced 30-day major complications in high-risk patients undergoing
cardiac surgery. (Crit Care Med 2016; 44:724–733)
Eduardo A. Osawa, MD, PhD1; Andrew Rhodes, M(Res)2; Giovanni Landoni, MD, PhD3;
Filomena R. B. G. Galas, MD, PhD1; Julia T. Fukushima, MSc1; Clarice H. L. Park, MD, PhD1;
Juliano P. Almeida, MD, PhD1; Rosana E. Nakamura, MD, PhD1; Tania M. V. Strabelli, MD, PhD1;
Brunna Pileggi, MD1; Alcino C. Leme, MD, PhD1; Evgeny Fominskiy, MD, PhD3; Yasser Sakr, MD, PhD4;
Marta Lima, MD1; Rafael A. Franco, MD, PhD1; Raquel P. C. Chan, MD, PhD1; Marilde A. Piccioni, MD, PhD1; Priscilla Mendes, RN1; Suéllen R. Menezes, RN1;
Tatiana Bruno, RN1; Fabio A. Gaiotto, MD, PhD5; Luiz A. Lisboa, MD, PhD5, Luiz A. O. Dallan, MD, PhD5, Alexandre C. Hueb, MD, PhD5;
Pablo M. Pomerantzeff, MD, PhD5, Roberto Kalil Filho, MD, PhD5; Fabio B. Jatene, MD, PhD5;
Jose Otavio Costa Auler Junior, MD, PhD1; Ludhmila A. Hajjar, MD, PhD1;
Enhanced recovery after surgery in a single high-volume surgical oncology unit: Details matter
Benefits of ERAS protocol have been well documented; however, it is unclear whether the improvement stems from the protocol or shifts in expectations.
Interdisciplinary educational seminars were conducted for all health professionals. However, one test surgeon adopted the protocol.
Protocol components included preoperative immunonutrition, clear liquids until 2 hours before surgery, carbohydrate loading until 2–3 hours before surgery, epidural catheter that were offered to all patients undergoing laparotomy, loading dose of gabapentin, intraoperative goal-directed resuscitation with LIDCO monitor
394 patients undergoing elective abdominal surgery from June 2013-April 2015 with a median age of 63 years were included.
A majority were female (51.8%) and white (59.9%) with a Charlson Comorbidity Index (CCI) score of 0-2 (40.4%) and Clavien complication
grade of 0-I (63.2%).
The implementation of ERAS protocol resulted in a decrease in the length of stay (LOS) (6.0 vs. 8.0 days; p= 0.016) and mortality
(0% vs. 2.9%; p= 0.033), whereas the difference in cost ($21,674 vs. $25,994; p= 0.060) was found to be insignificant.
Gender (p= 0.63), age (p= 0.36), race (p= 0.89), type of surgery (p= 0.49), comorbidities (p= 0.76), complications (p= 0.31), and readmission
rates (p= 0.21), were similar.
For the test surgeon, the ERAS protocol was associated with decreased LOS (6.2 vs. 9.6 days, p= 0.024), cost ($21,674 vs. $30,380, p= 0.029),
and mortality (0 vs. 3.3%, p= 0.044); differences in complications (grade II-V 32.2 vs. 42.6%, p= 0.064) and readmission rates
(11.5 vs. 21.4%, p= 0.076) did not reach significance.
For the control providers in this unit, the LOS, cost, mortality, readmission rates, and complications remained similar both before and after
the implementation of ERAS.
An ERAS protocol on the single high-volume surgical unit decreased the cost, LOS, and mortality.
Timothy L. Fitzgerald1,2, MD, Catalina Mosquera1,2, MD, Nicholas J. Koutlas1, Nasreen A. Vohra1,2, MD, Kimberly Lee, RN, Emmanuel E. Zervos1,2, MD
Application of LiDCOrapid in peri-operative fluid therapy for aged patients undergoing total hip replacement
To explore a good strategy for fluid therapy, we observed the effect of application of LiDCOrapid on peri-operative hypotension and complications in aged patients undergoing total hip replacement, performed un¬der combined spinal-epidural anesthesia (CSEA).
Forty patients were randomly divided into normal fluid therapy group (group N) and LiDCOrapid guiding fluid therapy group (group L). For group N, anytime mean arterial pressure (MAP) was less than 65 mmHg, a rapid intravenous infusion of 150 ml hydroxyethyl starch solution (HES, 130/0.4, 6%) was given.
For group L, whenever stroke volume variation (SVV) was more than 10%, HES (130/0.4, 6%) was also given to patients until SVV returned to normal limits. After administration of HES, MAP still less than 65 mmHg called for 25-50 μg of phenylephrine to be given to maintain normal MAP in both groups.
Heart rate (HR), MAP and lactate level of arterial blood (LAC) was compared between the two groups as prior to anesthesia (T0); instantly (T1), 15 min (T2), 30 min (T3), 60 min (T4), 90 min (T5) after spinal anesthesia; and at the end of surgery (T6).
MAP and HR were significantly higher in group L than in group N at T4 to T6 (all P<0.05).
LAC was significantly lower in group L than in group N at T5 and T6 (all P<0.05).
Phenylephrine requirements and incidences of peri-operative complications were also significantly lower in group L than in group N (all P<0.05).
LiDCOrapid may be used in fluid therapy for aged patients undergoing total hip replacement.
Guang Han, Kun Liu, Hang Xue, Ping Zhao
Use of a Care Bundle to Reduce Mortality after Emergency Laparotomy
This study, in four acute trusts, concludes that the implementation of an evidence-based care bundle for patients undergoing emergency laparotomy was associated with a significant reduction in the risk of death following the surgery. The emergency laparotomy pathway quality improvement care (ELPQuiC) bundle included goal-directed fluid therapy provided throughout the study using the LiDCOrapid cardiac output monitor both during surgery and for 6 hours while the patient was cared for in the intensive care unit.
The care bundle used consisted of:
An initial assessment with an early warning score assessed on presentation
Early administration of antibiotics
An interval between decision and operation of less than 6 hours
Goal-directed fluid therapy using cardiac output monitoring (via LiDCOrapid)
Postoperative intensive care
The study also noted that "significant changes in both the use of goal-directed fluid therapy and admission to ICU were found across almost all of the participating sites. These two elements of the bundle may have the greatest impact in reducing mortality in other hospitals and healthcare systems where these standards of care are not met routinely."
The study, showed that the number of lives saved per 100 patients treated rose from 6.47 to 12.44 and the overall adjusted risk of 30-day mortality significantly decreased from 15.6% to 9.6%. The authors conclude that 5.97 more lives saved per 100 patients treated overall compared with outcomes prior to implementation of the ELPQuiC bundle.
S. Huddart, C. J. Peden, M. Swart, B. McCormick, M. Dickinson, M. A. Mohammed and N. Quiney (2014) British Journal of Surgery 2014; 10.1002/bjs.9658
Enhanced Recovery in the Resection of Colorectal Liver Metastases
This retrospective analysis sought to assess the effects of an evolving ERAS programme in patients undergoing hepatectomy for the treatment of colorectal metastasis. Both LiDCO and PiCCO were used as part of the ERAS programme to manage fluids and optimise perfusion. The aim of this 304 patient study was to compare the early and later phase of the ERAS programme and to assess how an evolved programme with higher compliance would affect outcomes. The authors found that length of stay reduced as experience of ERAS increased: although median length of stay remained unchanged (6 days), the probability of hospitalisation beyond 10 days was 25% in the early cohort compared with 7% in the later cohort.
Critical care utilisation reduced over time (75.5% vs. 54.7%, P<0.0001) a significant reduction for the requirement for ICU resources and cost.
Whist a progressive reduction in hospitalisation and critical care utilisation was observed,the morbidity and mortality were the same in both groups. Costs were reduced with no adverse effect on patient outcome.
Dunne D, Yip V, Jones R, McChesney E, Lythgoe D, Psarelli E, Jones L, Lacasia-Purroy C, Malik H, Poston G, Fenwick S (2014) J Surg Oncol Apr 8. doi: 10.1002/jso.23616
Reduced Length of Hospital Stay in Colorectal Surgery after Implementation of an Enhanced Recovery Protocol
Data were collected from patients undergoing open or laparoscopic colorectal surgery prior to and post the implementation of an ERAS protocol. There were 142 patients in the ERAS group whose outcomes were compared to 99 patients in the traditional care group. Three key outcomes in the study were length of stay post operatively, the incidence of post-operative urinary tract infections and the readmission rates. The median LOS was 5 days in the ERAS group compared with 7 days in the traditional group (P < 0.001). This reduction in LOS was significant for both procedures. ERAS patients had fewer urinary tract infections (13% vs 24%, P = 0.03) and the 30 day readmission rates were lower in ERAS patients (9.8% vs 20.2%, P = 0.02). All patients received intraoperative goal-directed fluid therapy with a minimally invasive cardiac output monitor. Boluses of IV colloid were given to optimise stroke volume where required. The monitors used were either the Esophageal Doppler (Deltex Medical Group plc) or the LiDCOrapid when invasive arterial blood pressure monitoring was performed. The need for an arterial line was based on the clinical judgment of the anaesthetist in charge of the patient. The study concludes that implementation of an Enhanced Recovery After Surgery (“ERAS”) programme for colorectal surgery was associated with a significantly reduced length of stay (“LOS”) and incidence of urinary tract infection.
Miller T, Thacker J, White W, Mantyh C, Migaly J, Jin J, Roche A, Eisenstein E, Edwards R, Anstrom K, Moon R, Gan TJ (2014) Anesth Analg 2014;118:1052–61
Cost-Effectiveness Analysis of Postoperative Goal Directed Therapy:
Clinicians from St George's Hospital have been delivering goal directed therapy, using the LiDCOplus monitor, for high risk patients in the postoperative period for at least 8 years (targeting oxygen delivery in order to repay perioperative oxygen debt) and have now investigated the cost effectiveness of this therapy as part of postoperative management of this group of patients. The authors modelled both short and long term clinical and financial benefits of implementing goal directed therapy and conclude that it is both clinically- and cost-effective, providing significant benefits with respect to clinical and financial outcomes. In the short term model, GDT decreased costs by £2,631.77/patient and by £2,134.86/hospital survivor. In the long term, GDT was found to prolong quality-adjusted life expectancy (by 9.8 months) and to bring incremental cost savings of £1,285.77
Ebm C, Cecconi M, Sutton L, Rhodes A (2014) A Cost-Effectiveness Analysis of Postoperative Goal-Directed Therapy for High-Risk Surgical Patients Critical Care Medicine DOI: 10.1097/CCM0000000000000164
Multimodal Monitoring In Elderly High Risk Vascular Patients is Associated with Reduced Mortality:
Dr David Green and colleagues at Kings College Hospital have been routinely using multimodal monitoring in high risk vascular elderly patients for 6 years and have now published a retrospective analysis of data covering 120 patients undergoing major peripheral vascular surgery between October 2007 and January 2012. Cardiac output, bispectral index and cerebral oxygenation measurements were all used in this cohort of patients, with the aim of pre-emptively reducing build-up of oxygen debt. A key element is that pre-induction values were used to provide the baseline for each individual patient, rather than using a protocol-driven approach.
The results of this analysis show that:
30 day mortality at 0.8% (one patient) was significantly lower than the 9% mortality (eleven patients) predicted by the V-POSSUM scoring
amputation rate was low at less than 2% after one year.
Postoperatively only 8% (10 patients) went to a high dependency unit - with the great majority being able to be nursed post-operatively in
lower cost, conventional general wards.
AAGBI Guidelines for Perioperative care of the elderly
Co-incidentally this work by Dr Green is published at the same time as the AAGBI Guidelines for Peri-operative care of the elderly in which multimodal monitoring is recommended, and demonstrates the effectiveness of the recommendations. In particular the recommendations include:
Use of continuous intra-arterial blood pressure monitoring, started before anaesthesia, to reduce the incidence of hypotensive episodes that can occur between intermittent blood pressure measurements;
Fluid monitoring - Fluid and electrolyte therapy is challenging in older surgical patients. Pathophysiological changes in elderly patients reduce the ability to compensate for blood/ fluid loss and reduces tolerance to unmonitored / incautiously administered intravenous fluids. ‘Fluid therapy should be administered with great care and in divided boluses to allow assessment of response’ - ideally this requires a cardiac output monitoring device to be used.
Depth of anaesthesia monitors: ‘should be used to guide depth of anaesthesia and sedation. The doses of anaesthetic agents required to induce and maintain general anaesthesia and sedation decrease with increasing age, and failure to adjust doses (which is common) can result in relative overdose and prolonged, significant hypotension. Depth of anaesthesia monitors are recommended as an option by NICE “during any type of general anaesthesia in patients at higher risk of adverse outcomes. This includes … patients at higher risk of excessively deep anaesthesia” A ‘triple low’ of low BIS and hypotension despite low inspired inhalational agent concentration is associated with higher mortality and prolonged inpatient stay.’
Green D, Bidd H, Rashid H Multimodal intraoperative monitoring: An observational case series in high risk patients undergoing major peripheral vascular surgery. International journal of surgery 2014; 12: 231-6.
Peri-operative care of the elderly 2014
Association of Anaesthetists of Great Britain and Ireland
Post operative surgical Goal Directed Therapy:
The effect of post operative goal directed therapy on the incidence of complications and duration of hospital stay in patients was investigated by Pearse et al (2005). The LiDCOplus hemodynamic monitor running the PulseCO algorithm was used to monitor % stroke volume change following a 250 ml bolus of intra venous colloid. The goal was to achieve with each bolus at least a 10% rise in stroke volume until a target oxygen delivery (DO2I) of 600 ml/min/m2 was achieved. If euvolemia was achieved prior to reaching the oxygen delivery target, then dopexamine (an inotrope) was administered up to a maximum of 1µgkg-1m-2 in order to reach the target. Sixty two patients were randomized to GDT and 60 patients to the control group. Fewer GDT patients developed complications (27 patients (44%) vs 41 patients (68%) p = 0.003). The median duration of hospital stay in the GDT group was significantly reduced (11 days vs 14 days) and the mean stay was reduced by 12 days (17.5 days versus 29.5 days) a 41% reduction (95% confidence intervals p = 0.001). St Georges Hospital now routinely optimize the majority high-risk surgery patients post operatively in the ICU following surgery saving an average of £4,800 per patient.
Figure below is data from the St Georges oxygen delivery GDT study.
Pearse R, Dawson D, Fawcett J, Rhodes A, Grounds RM, Bennett ED (2005) Early goal-directed therapy after major surgery reduces complications and duration of hospital stay. A randomised, controlled trial. Crit Care 9 (6) 687-693
Peri-operative GDT study (intra and post op):
The results of the clinical study from investigators in Brazil show that the LiDCOplus cardiac output monitor enabled physicians to safely reduce the administration of background maintenance fluids, while maintaining the necessary oxygen delivery to patients during and after surgery. The optimal protocol reduced fluid load while maintaining oxygen delivery and this in turn cut the rate of postoperative complications by 67.5%. The prospective randomized trial was conducted in 88, older, high-risk, major surgery patients, using LiDCOplus to monitor cardiac output, fluids and to optimize oxygen delivery both during and for eight hours after surgery. In one group normal maintenance fluids were given and in the other group the total fluid load was restricted, to avoid complications associated with administration of potentially excessive maintenance fluids.
Both groups of patients achieved high levels of oxygen delivery and in both groups complication rates were reduced from predicted historic levels. The best results were seen in the optimized oxygen delivery and fluid restricted patient group where only 20% of patients suffered a complication. The expected rate of complications without monitoring in this high risk group of patients was 61.5%.
The authors stated: "In conclusion, perioperative goal-directed hemodynamic therapy with a protocol incorporating restrictive fluid maintenance and inotropic therapy to achieve the best possible oxygen delivery in very high-risk surgical patients can be easily performed with the use of minimally invasive hemodynamic monitoring to obtain continuous monitoring of cardiac output, and is related to better outcomes."
Lobo S et al ., (2011) Restrictive strategy of intraoperative fluid maintenance during optimization of oxygen delivery decreases major complications after high-risk surgery. Critical Care vol 15: R226 doi:10.1186/cc10466
Shock patients in an ICU setting:
A study from the University of Iowa in the USA has shown that using LiDCO's hemodynamic monitoring technology significantly reduces the mortality rate in patients treated for shock. The results of the study were published in the Journal of Critical Care.
This study compared the clinical outcomes of 237 shock patients treated following either no hemodynamic monitoring, invasive monitoring (pulmonary artery or central venous catheter) or with LiDCO's minimally invasive LiDCOplus Monitor. Use of the different technologies resulted in significant changes in both the fluid and drugs used to restore the patients' blood pressure and cardiac output. Treatment of patients using LiDCO's monitor significantly reduced the observed mortality rate to 13% against 32% and 20% in the invasively monitored and 37% in the unmonitored patient groups. In the paper, The University of Iowa investigators concluded: "The results of our study extend the findings of Pearse et al who reported that supportive care guided by lithium dilution and arterial waveform [LiDCOplus Monitor] assessments of cardiac output was associated with reduction of perioperative morbidity as compared with conventional assessment."
Hata J, Stotts C, Shelsky C, Bayman E, Frazier A, Wang J, Nickel E (2011) Reduced mortality with noninvasive hemodynamic monitoring of shock. J Crit Care vol 26 (2):224. E1-8
Transplantation organ donor optimization:
Brain death causes dramatic hemodynamic instability. Inadequate resuscitation may lead to ischemic injury and inflammation resulting in less organs deemed healthy for transplantation from organ donors. Murugan and co investigators at Pittsburgh (2009), investigated whether donor preload fluid responsiveness is associated with an increased inflammatory response and lower organ yield for transplantation. They showed that preload responsiveness (ie a LiDCO monitor PPV of > 13%) was associated with plasma interleukin-6 and tumor necrosis factor concentrations greater than in the euvolemic / preload unresponsive donors. Fewer organs were transplanted (half) from preload responsive donors 1.8 ± 0.9 vs 3.7 ± 2.5 (p = 0.35). The authors concluded that "Our data provide the rationale that a protocol guided donor resuscitation strategy using functional hemodynamic monitoring following brain death may have the potential to reduce ischemic and inflammatory organ injury and improve organ viability and yield from transplantation." The authors of this trial then showed that orgen transplanted from LiDCO resuscitated donors performed better in the recipients - with less hospital days post transplantation. This data was then used as support for the multi centre randomized Monitor transplantation now in progress (see details section 4.3) using LiDCO for the optimization of the donors.
Murugan R, Venkataraman R, Wahed A, Elder M, Carter M, Madden N, Kellum J (2009) preload responsiveness is associated with increased interleukin-6 and lower organ yield from brain-dead donors. Crit Care Med Vol. 37 No. 8, 2387 – 2393
High-risk abdominal & bariatric surgery:
High-risk abdominal surgery has been reported to have patient morbidity between 20-40% and a mortality of up to 10%. Koff and co-workers (2010) performed a prospective observational study to evaluate the effect on length of stay (LOS) in high-risk abdominal surgery patients with adequate resuscitation, based on the percentage of intraoperative time that the patient spent below a LiDCO PPV threshold of 13%. The LiDCOrapid monitor was used to report PPV%. In patients that had adequate resuscitation a significant decrease in LOS was observed from 10.1 to 6.1 days respectively (p<0.02 95% CI=-7.20 to -0.79). The adequate resuscitation group had a reduction in postoperative complication rates 7 vs. 1 (P= 0.03). The authors concluded "A significant decrease in LOS was noted in the adequate resuscitation group based on PPV threshold audit analysis of 25% case duration. This group also had a reduction in post-operative complications.”
Koff M, Richard K, Novak M, Canneson M, Dodds T (2010) Elevated PPV Predicts an Increased Length of Stay and Morbidity during High risk Abdominal Surgery. Proceedings of the 2010 Annual Meeting of the ASA
Laparoscopic Bariatric Surgery:
Jain and Dutta (2010) investigated the use of LiDCO’s stroke volume variation as a guide to fluid administration in morbidly obese patients undergoing laparoscopic bariatric surgery. SVV was used as a guide for intra operative fluid administration in 50 morbidly obese patients undergoing bariatric surgery. Using SVV they were able to maintain hemodynmaic parameters (cardiac output, stroke volume and heart rate) within 10% of the preoperative level control level. The static parameter CVP was not found to correlate with SVV and the authors feel that the CVP may be misleading and lead to more fluids being given than is necessary. The authors concluded "SVV-guided optimization may have a crucial significance in limiting excessive fluid administration in morbidly obese patients undergoing bariatric surgery."
Jain A & Dutta A (2010) Stroke Volume Variation as a Guide to Fluid Administration in Morbidly Obese Patients Undergoing Laparoscopic Bariatric Surgery. Obes Surg DOI 10.1007/s11695-009-0070
Head and neck cancer surgery:
Eley & Watt-Smith et al., (2009) examined the intra-operative use of LiDCOplus monitor to see if there was an effect on the volume of intravenous fluids used by anaesthetists during free flap surgery for head and neck cancer. They showed that the use of the LiDCO parameters had reduced the volume of intra-operative fluids administered. They concluded that the LiDCO monitor "is suitable for use in patients undergoing head and neck cancer surgery" and that "the system provides the anesthetist with another indicator of fluid filling, which is more reliable than CVP, since it is unaffected by change in patient positioning."
Eley K, Watt-Smith S (2009) Intra-operative use of LiDCO – is there an effect on the volume of intravenous fluids used by anaesthetists during free flap surgery for head and neck cancer? Brit Journal of Oral and Maxillofacial Surgery Vol 47 Issue 7 e15
Congestive heart failure patients:
These investigators showed that the core PulseCO algorithm could discriminate < 5% changes of stroke volume in heart failure patients undergoing biventricular pacemaker resynchronization. They further showed that patients with > 5% improvement of stroke volume performed better at 2 mths follow up clinics in terms of length of 6 min walk, and improvement in echocardiographic dyssynchrony profile.
Dizon J, Quinn T, Cabreriza S, Wang D, Spotnitz H, Hickey K, Garan H (2010) Real-time Stroke Volume Measurements for the Optimization of Biventricular Pacing Parameters. Europace Sep; 12(9):1270 – 4
Emergency laparotomy is a high-risk surgery procedure with a high morbidity and mortality rate. The need for change to a more coordinated approach to emergency general surgery of the elderly has been highlighted by the NCEPOD report (2011) and the Royal College of Surgeons report (2011) regarding the "forgotten” higher risk general surgical patient. The delivery of best practice evidence based peri-operative care is strongly suggested. These investigators have started to implement an integrated care pathway for emergency laparotomy which may include goal-directed therapy (GDT) using CardioQ-ODM or the LiDCOrapid. A retrospective audit of 57 emergency laparotomies conducted between August and October 2010 was conducted. GDT was used in 49% of total cases and 64% of cases were ASA grade 3 or greater. Higher risk patients with an ASA grade of ≥ 3 who received goal directed fluid therapy had a median length of stay of 12 days compared to 20.5 days in those managed without GDT. The use of GDT amongst the trainees (31%) was lower than seen with consultants (61%). Given these positive results the lower use levels of trainees is being addressed by new trainees getting more training and encouragement in the use of cardiac output monitoring with the aim of reducing length of stay.
Beauchamp N, Mowat I, Dickinson M. (2012) Outcomes in emergency laparotomies: local results and response to a national audit. Presented at the January 2012 Winter Scientific Meeting of the AAGBI, London.
Investigators at the Royal Surrey County Hospital (RSCH) in Guildford took the standardized oesophagectomy clinical pathway (SOCP) developed at the Department of Thoracic Surgery at Virginia Mason Medical Centre (VMMC) in the US, and applied it to patients undergoing oesophagectomy at the RSCH. The objective was to see whether a SOCP could be transferred between hospitals to improve patient outcomes. Goal-directed fluid therapy using the LiDCOrapid intra operatively and for six hours post surgery was applied to all patients under the standardized care pathway at RSCH. Intraoperative fluid management is an established standard of care at RSCH.
Patients were grouped based on whether or not they were operated on under the SOCP (group 3 and group 1 respectively) and were compared with each other as well as with a US group who had been operated under the SOCP at VMMC (group 4).
Fewer patients experienced postoperative complications following introduction of the clinical pathway (9 of 12 in group 1, versus 4 of 12 in group 3; P = < 0.041). Statistical analysis indicated that the SOCP was the only variable significantly associated with a reduced incidence of postoperative complications.
Significant improvements seen following implementation of the clinical pathway included the proportion of patients mobilizing on postoperative day 1 (1 of 12 in group 1 versus 12 of 12 in group 3; P < 0.001), median length of critical care stay (4 (range 2–20) versus 3 (1–5) days respectively; P < 0.001) and median length of hospital stay (17 (12–30) versus 7 (6–37) days; P = 0.022). Statistical analysis confirmed the SOCP to be the only variable significantly associated with a reduced length of hospital stay
Preston SR, Markar SR, Baker CR, Soon Y, Singh S and Low DE Impact of multidisciplinary standardized clinical pathway on perioperative outcomes in patients with oesophageal cancer. Br J Surg 2013 Jan;100(1):105-12. DOI: 10.1002/bjs.8974
Open Liver Resection:
This clinical trial involved 91 patients and was carried out at the Royal Surrey County Hospital. The 91 patients were randomly allocated to receive standard care or an Enhanced Recovery Programme (“ERP”) following open liver resection. The patients in the ERP were monitored using the LiDCOrapid system.
The trial confirmed that using an ERP that included goal directed fluid therapy (GDFT) monitored by the LiDCOrapid system reduces the length of stay by three days for patients undergoing open liver resection and post-operative complications were also reduced (from 27% in the control arm to 7% in the ERP arm).
Jones C, Kelliher L, Dickinson M, Riga A, Worthington T, Scott M J, Vandrevala T, Fry C H, Karanjia N and Quiney N. Randomized clinical trial on enhanced recovery versus standard care following open liver resection. Br J Surg 2013 Jul;100(8):1015-24. Doi: 10.1002/bjs.9165
This is just a selection of the clinical studies that have been published. For a full bibliography please Download here.